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Objectives We sought to evaluate the impact of crossing strategy on the incidence of periprocedural myocardial infarction (PMI) during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Background: The optimal technique for crossing coronary CTOs remains controversial. Methods: We retrospectively examined the incidence of PMI among 184 consecutive patients who underwent CTO PCI at our institution between 2012 and 2015. Creatine kinase-myocardial band fraction (CK-MB) and troponin were measured before and after PCI in all patients. PMI was defined as CK-MB increase ≥3× upper limit of normal (ULN). Results: Mean age was 65 ± 8 years, 98% of patients were men, 57% had diabetes mellitus, 36% were current smokers, 38% had prior heart failure, 31% had prior coronary artery bypass graft surgery (CABG), and 55% had prior PCI. The retrograde approach was used in 38% of cases. As compared with antegrade wire escalation and antegrade dissection/re-entry, use of the retrograde approach was associated with higher J-CTO (Multicenter CTO Registry of Japan) scores (P

Summary Background Few studies have examined the efficacy of drug-eluting stents (DES) for reducing aortocoronary saphenous vein bypass graft (SVG) failure compared with bare-metal stents (BMS) in patients undergoing stenting of de-novo SVG lesions. We assessed the risks and benefits of the use of DES versus BMS in de-novo SVG lesions. Methods Patients were recruited to our double-blind, randomised controlled trial from 25 US Department of Veterans Affairs centres. Eligible participants were aged at least 18 years and had at least one significant de-novo SVG lesion (50–99% stenosis of a 2·25–4·5 mm diameter SVG) requiring percutaneous coronary intervention with intent to use embolic protection devices. Enrolled patients were randomly assigned, in a 1:1 ratio, by phone randomisation system to receive a DES or BMS. Randomisation was stratified by presence or absence of diabetes and number of target SVG lesions requiring percutaneous coronary intervention (one or two or more) within each participating site by use of an adaptive scheme intended to balance the two stent type groups on marginal totals for the stratification factors. Patients, referring physicians, study coordinators, and outcome assessors were masked to group allocation. The primary endpoint was the 12-month incidence of target vessel failure, defined as the composite of cardiac death, target vessel myocardial infarction, or target vessel revascularisation. The DIVA trial is registered with ClinicalTrials.gov, number NCT01121224. Findings Between Jan 1, 2012, and Dec 31, 2015, 599 patients were randomly assigned to the stent groups, and the data for 597 patients were used. The patients' mean age was 68·6 (SD 7·6) years, and 595 (>99%) patients were men. The two stent groups were similar for most baseline characteristics. At 12 months, the incidence of target vessel failure was 17% (51 of 292) in the DES group versus 19% (58 of 305) in the BMS group (adjusted hazard ratio 0·92, 95% CI 0·63–1·34, p=0·70). Between-group differences in the components of the primary endpoint, serious adverse events, or stent thrombosis were not significant. Enrolment was stopped before the revised target sample size of 762 patients was reached. Interpretation In patients undergoing stenting of de-novo SVG lesions, no significant differences in outcomes between those receiving DES and BMS during 12 months of follow-up were found. The study results have important economic implications in countries with high DES prices such as the USA, because they suggest that the lower-cost BMS can be used in SVG lesions without compromising either safety or efficacy. Funding US Department of Veterans Affairs Cooperative Studies Program.

Objective To compare long-term clinical outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) using the retrograde and antegrade approach. Background There is limited long-term clinical outcomes data on the retrograde approach to CTO PCI. Methods We performed a retrospective analysis of the long-term clinical outcomes of 193 consecutive patients who underwent successful CTO PCI at our institution between March 2008 and December 2011. Results Mean age was 63.6 ± 8.3 years. The target vessel was right coronary artery in 52.6%, left anterior descending artery in 24.5% and circumflex in 21.4% of cases. The retrograde approach was used in 41 patients (21.2%). The mean stent length was longer in the retrograde group (83 ± 32 vs. 64 ± 32 mm, P = 0.001). Two major procedural complications occurred, both in the retrograde group (P = 0.012). During a median follow-up of 2.0 years compared to the antegrade CTO PCI group, patients who underwent retrograde CTO PCI were more likely to undergo target lesion revascularization (TLR) (45.6% vs. 25.7%, P = 0.006). No significant difference was observed in the incidence of all-cause mortality, myocardial infarction, non-target vessel revascularization, or coronary artery bypass graft surgery between the 2 groups. On multivariate analysis, stent length was the only independent predictor of TLR during follow-up. Conclusions Retrograde CTO PCI was associated with higher incidence of TLR, but similar incidence of death and myocardial infarction compared to antegrade CTO PCI. These findings likely reflect the higher complexity of CTO lesions treated with the retrograde approach. (J Interven Cardiol 2014;27:465–471)

Aortocoronary dissection can complicate percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs).We retrospectively examined the frequency and outcomes of aortocoronary dissection among 336 consecutive CTO PCIs performed at our institution between 2005 and 2012 and performed a systematic review of the published literature.Aortocoronary dissection occurred in six patients (1.8%, 95% confidence intervals 0.7%, 3.8%). All aortocoronary dissections occurred in the right coronary artery (CTO target vessel in five patients and donor vessel in one patient). The baseline clinical characteristics of patients with and without aortocoronary dissection were similar. Compared to patients without, those with aortocoronary dissection were more likely to undergo crossing attempts using the retrograde approach (25% vs. 67%, P = 0.036) and experience a major complication (2.4% vs. 33.3%, P = 0.008). Technical and procedural success rates were similar in both groups. Of the six patients with aortocoronary dissection one underwent emergency coronary bypass graft surgery (CABG), four were treated with ostial stenting, and one was treated conservatively without subsequent adverse clinical outcomes. Systematic literature review provided 107 published cases of aortocoronary dissection during PCI, that occurred mainly in the right coronary artery (74.8%) and were treated with stenting (49.5%), emergency CABG (29%), or conservatively (21.5%).Aortocoronary dissection is an infrequent complication of CTO PCI and although it can be treated with stents in most patients, it may infrequently require emergency CABG.

Objectives We sought to determine the contemporary prevalence and management of coronary chronic total occlusions (CTO) in a veteran population. Background The prevalence and management of CTOs in various populations has received limited study. Methods We collected clinical and angiographic data in consecutive patients that underwent coronary angiography at our institution between January 2011 and December 2012. Coronary artery disease (CAD) was defined as ≥50% diameter stenosis in ≥1 coronary artery. CTO was defined as total coronary artery occlusion of ≥3 month duration. Results Among 1,699 patients who underwent angiography during the study period, 20% did not have CAD, 20% had CAD and prior coronary artery bypass graft surgery (CABG), and 60% had CAD but no prior CABG. The prevalence of CTO among CAD patients with and without prior CABG was 89 and 31%, respectively. Compared to patients without CTO, CTO patients had more co-morbidities, more extensive CAD and were more frequently referred for CABG. Percutaneous coronary intervention (PCI) to any vessel was performed with similar frequency in patients with and without CTO (50% vs. 53%). CTO PCI was performed in 30% of patients without and 15% of patients with prior CABG with high technical (82 and 75%, respectively) and procedural success rates (80 and 73%, respectively). Conclusions In a contemporary veteran population, coronary CTOs are highly prevalent and are associated with more extensive co-morbidities and higher likelihood for CABG referral. PCI was equally likely to be performed in patients with and without CTO. © 2013 Wiley Periodicals, Inc.

Objectives: This study sought to compare and contrast use and radiation exposure using radial versus femoral access during cardiac catheterization of patients who had previously undergone coronary ...

We examined a contemporary, unselected cohort of patients with coronary chronic total occlusions (CTOs) to determine the impact of CTO revascularization on long-term outcomes.We retrospectively assessed the impact of CTO revascularization on clinical outcomes of consecutive patients found to have a CTO during coronary angiography performed at our institution during 2011 and 2012. The primary endpoint was the incidence of a major adverse cardiac event (MACE, defined as a composite of death, myocardial infarction, stroke, and target-vessel revascularization [TVR]). Survival analysis was performed in the overall and propensity-matched retrospective cohorts of patients stratified by prior coronary artery bypass graft (CABG) surgery. Propensity-adjusted hazard ratio (HR) and 95% confidence interval (95% CI) were calculated with Cox proportional hazards analysis. All analyses were by intention to treat.Of 624 patients (319 without prior CABG and 305 with prior CABG) included in the present analysis, CTO revascularization (surgical or percutaneous) was attempted in 60% and 16% of patients without and with prior CABG, respectively. During a median follow-up of 26 months (range, 18-40 months), the incidence of MACE was 20.6%. CTO revascularization (achieved or attempted) was associated with lower incidence of MACE among patients without prior CABG (propensity-adjusted HR, 0.51; 95% CI, 0.27-0.94; P=.03), but not among prior CABG patients (propensity-adjusted HR, 1.38; 95% CI, 0.64-2.96; P=.41).In a large, unselected patient population with coronary CTOs, a CTO revascularization attempt was associated with lower incidence of subsequent MACE among patients without prior CABG, but not among prior CABG patients.

We investigated whether side-branch loss during chronic total occlusion (CTO) percutaneous coronary intervention (PCI) could adversely impact clinical outcomes.Side-branch occlusion during PCI has been associated with periprocedural myocardial infarction and higher incidence of major adverse cardiac event (MACE), but has received limited study in CTO-PCI.We retrospectively reviewed the medical records and coronary angiograms for 109 consecutive CTOPCI cases performed at our institution during 2012 and 2013. Post-PCI patency of ≥1 mm diameter side branches and associated clinical outcomes were assessed.Mean age was 65 ± 8 years and 99.1% of the patients were men. The CTO target vessel was the right coronary artery (54%), circumflex (26%), and left anterior descending artery (20%). Side-branch loss occurred in 28 cases (25.7%) due to antegrade dissection/reentry (n = 9), retrograde dissection/reentry (n = 5), stenting over the branch (n = 12), and dissection during antegrade crossing attempts (n = 2). Recanalization of the occluded side branch was pursued in 8 cases (28.6%) and was successful in 4 patients. Patients with side-branch loss had higher post-PCI increase in CK-MB levels (8.4 ng/mL [interquartile range, 2.7-33.5 ng/mL] vs 1.8 ng/mL [interquartile range, 0.025-6.775 ng/mL]; P.001) and higher 12-month incidence of all-cause death (17.3% vs 2.8%; P=.02) and cardiovascular death (7.4% vs 0.0%; P=.02).Side-branch loss occurs in approximately 1 in 4 CTO-PCIs and is associated with higher risk for periprocedural myocardial infarction and higher mortality.

Chronic Kidney Disease (CKD) prevalence rate among veterans has risen in the past decade. The CKD associations with long term mortality and cardiovascular adverse event risks after stented PCI are unknown among veterans population. This study extracted data from VA national Corporate Data Warehouse

Background: In percutaneous coronary intervention (PCI) of coronary chronic total occlusions (CTOs), inability to cross the lesion with a balloon is the second most common cause of technical failure following inability to cross the lesion with a guidewire. While various techniques have been reported for such "balloon uncrossable" CTOs, the frequency and outcomes of these techniques have received limited study. Methods: We retrospectively examined 373 consecutive CTO PCIs performed at our institution between 2005 and 2013 to determine the frequency and outcomes of “balloon uncrossable” CTOs. Results: Mean age was 63.7 ± 8.3 years and 98.9% of the patients were men. Twenty four patients (6.4%) were found to have a "balloon uncrossable" CTO. These patients had similar clinical and angiographic characteristics compared to the other CTO PCI patients (Table). Successful crossing of the lesion was achieved in 22 of 24 patients (91.7%) using a variety of techniques, such as successive balloon inflations (43.5%), microcatheter advancement (21.7%), laser (8.7%), increased guide catheter support (13.0%), and subintimal lesion crossing (13.0%) (Figure). Patients with “balloon uncrossable” CTOs had longer procedure time (184.5 ± 77.9 vs. 134.0 ± 69.0 min, p Conclusion: “Balloon uncrossable” CTOs occur in 6.4% of contemporary CTO PCIs and can be successfully treated in most patients using a variety of techniques.

The objective of the present study was to perform a systematic review and meta-analysis of studies reporting outcomes after first- and second-generation drug-eluting stent (DES) implantation in chronic total occlusions (CTOs).The effect of second- vs first-generation DESs on the outcomes after CTO percutaneous coronary intervention (PCI) has received limited study.As of May 2013, thirty-one published studies reported outcomes after DES implantation in CTOs: thirteen uncontrolled studies (3161 patients), three randomized (220 patients) and ten non-randomized (2150 patients) comparative studies with bare-metal stents (BMSs), and two non-randomized (685 patients) and three randomized (489 patients) comparative studies between first- and second-generation DESs. Data from the five studies comparing first with second-generation DESs were pooled using random-effects meta-analysis models.The median and mean duration of follow-up were 12 and 14.4 months, respectively. Compared to first-generation DESs, second-generation DESs were associated with lower incidence of death (odds ratio [OR], 0.37; 95% confidence intervals [CI], 0.15-0.91), target vessel revascularization (OR, 0.59; 95% CI, 0.40-0.87), binary angiographic restenosis (OR, 0.68; 95% CI, 0.46-1.01) and reocclusion (OR, 0.35; 95% CI, 0.17-0.71), but similar incidence of myocardial infarction (OR, 0.45; 95% CI, 0.10-1.95) and stent thrombosis (OR, 0.34; 95% CI, 0.07-1.59).Compared to first-generation DESs, second-generation DESs are associated with improved angiographic and clinical outcomes in CTO PCI and are the preferred stents for these challenging lesions.

Cardiologist Jerry Grodin, MD (Figure ​(Figure1),1), volunteered for the US Army Reserve soon after the terrorist attacks on September 11, 2001. He spent a tour of duty in 2004 with the 67th Combat Support Hospital in Mosul, Iraq. More recently, Major Grodin was reactivated and sent to the US Army's Landstuhl Regional Medical Center in Ramstein, Germany. He periodically writes letters to his colleagues. Baylor University Medical Center Proceedings will reprint occasional letters to inform the Baylor community of a perspective on the war and our soldiers. Dr. Grodin can be reached at jerrold.m.grodin@us.army.mil.

a complete coronary revascularization as compared to patients with incomplete revascularization (96% 3% vs. 78% 7%; p1⁄40.002); completeness of revascularization was inversely related to the risk of death (HR 0.10; p1⁄40.029). Conclusions: In patients with multiple CTOs a successful PCI of all CTOs was associated with increased cardiac survival, and completeness of revascularization was a strong predictor of survival.

We sought to examine the prevalence and management of coronary chronic total occlusions (CTO) within a contemporary veteran population. We collected clinical and angiographic data on 1,699 consecutive patients that underwent coronary angiography at our institution between January 2011 and December

This study sought to compare and contrast use and radiation exposure using radial versus femoral access during cardiac catheterization of patients who had previously undergone coronary artery bypass graft (CABG) surgery.Limited information is available on the relative merits of radial compared with femoral access for cardiac catheterization in patients who had previously undergone CABG surgery.Consecutive patients (N = 128) having previously undergone CABG surgery and referred for cardiac catheterization were randomized to radial or femoral access. The primary study endpoint was contrast volume. Secondary endpoints included fluoroscopy time, procedure time, patient and operator radiation exposure, vascular complications, and major adverse cardiac events. Analyses were by intention-to-treat.Compared with femoral access, diagnostic coronary angiography via radial access was associated with a higher mean contrast volume (142 ± 39 ml vs. 171 ± 72 ml, p0.01), longer procedure time (21.9 ± 6.8 min vs. 34.2 ± 14.7 min, p0.01), greater patient air kerma (kinetic energy released per unit mass) radiation exposure (1.08 ± 0.54 Gy vs. 1.29 ± 0.67 Gy, p = 0.06), and higher operator radiation dose (first operator: 1.3 ± 1.0 mrem vs. 2.6 ± 1.7 mrem, p0.01; second operator 0.8 ± 1.1 mrem vs. 1.8 ± 2.1 mrem, p = 0.01). Fewer patients underwent ad hoc percutaneous coronary intervention (PCI) in the radial group (37.5% vs. 46.9%, p = 0.28) and radial PCI procedures were less complex. The incidences of the primary and secondary endpoints was similar with femoral and radial access among PCI patients. Access crossover was higher in the radial group (17.2% vs. 0.0%, p 0.01) and vascular access site complications were similar in both groups (3.1%).In patients who had previously undergone CABG surgery, transradial diagnostic coronary angiography was associated with greater contrast use, longer procedure time, and greater access crossover and operator radiation exposure compared with transfemoral angiography. (RADIAL Versus Femoral Access for Coronary Artery Bypass Graft Angiography and Intervention [RADIAL-CABG] Trial; NCT01446263).

We evaluated the use of Google Glass for remote transthoracic echocardiography (TTE) video capture and interpretation. Google Glass was used to record 17 TTE studies with 25 key findings. Ten physicians (3 faculty and 7 fellow cardiologists) interpreted recordings on a) desktop, b) iPhone, c) iPad

Saphenous vein grafts (SVG) are used in most coronary artery bypass graft surgeries (CABG), but have high rates early and late occlusion. We sought to examine the pathogenesis of early SVG failure using serial optical coherence tomography (OCT) imaging. OCT was performed in 10 SVGs in 9 patients at

There is limited data on outcomes after implantation of second generation drug-eluting stents in coronary chronic total occlusions (CTOs). Our study's aim is to evaluate the frequency of angiographic restenosis and clinical outcomes after implantation of the everolimus-eluting stent (EES) in CTOs